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SHORT BOWEL SYNDROME: EARLY RESULTS OF PARENTERAL FISH OIL
E Altamimi1, M Al Hatlani1, J Al Hudaif2, B Cameron2, P Fitzgerald2, AMGA Sant’Anna1
1Divisions of Pediatric Gastroenterology; 2Pediatric Surgery, McMaster Children’s Hospital and McMaster University, Hamilton, Ontario
BACKGROUND: Short bowel syndrome (SBS) in the pediatric population can be the result of severe NEC, or congenital gut malformation (atresias, malrotation or volvulus). Parenteral nutrition associated liver dysfunction (PNALD) is a serious complication of SBS. The availability of parenteral fish oil (Omegaven™) is reported to reverse PNALD. We reviewed our initial experience using Omegaven™ in 5 infants with SBS, and compared the outcomes of those receiving it early vs. late in the course of their cholestasis.
METHODS: Retrospective review of the records of five SBS patients (08/06-10/07), evaluating their etiologies, treatment, course and complications.
RESULTS: Of our five patients two were born with gastroschisis and multiple intestinal atresias, two had volvulus and one had severe NEC. There was no mortality. Long term TPN was required in all our patients (230-425 days) and four of them are still on TPN. All of them developed PNALD. Early introduction of parenteral fish oil (on average of 54 days post cholestasis: BC=>50) was associated with smoother course and faster resolution of their cholestasis (bilirubin normalized 85 days on average) in comparison with later introduction (introduced after >100 days of cholestasis, required >240 days for resolving of cholestasis or decreasing its progression). Four out of five patients were discharged home; three of them on home TPN. Re-introduction of intralipid 20% after resolution of cholestasis with parenteral fish oil was not associated with re-elevation of conjugated bilirubin or liver enzymes. Line sepsis was the most common complication; patients had from 2-7 episodes of line infections. Coagulase negative staphylococcus was the most common microorganism. The usage of prophylactic oral antibiotics (after 1st episode of sepsis) was not associated with the evolution of resistant microorganisms. D-lactic acidosis was not demonstrated in any of our patients. Breast milk was well tolerated in these patients; when not available, hydrolysed or amino acid formulas were well tolerated.
CONCLUSION: Although our patients require further follow-up, our data supports previous reports describing parenteral fish oil as a safe lipid source in TPN and it’s ability to reverse the liver dysfunction related to the long-term use of TPN. We conclude that parenteral fish oil should be used as early as possible in patients with PNALD.